This document discusses the differences between incision, excision, and resection procedures in ICD-9-CM and ICD-10-PCS coding. It defines each term and provides examples. Incision refers to a cut made during surgery, while excision means cutting out a portion of a body part and resection is cutting out or removing all of a body part. In ICD-10-PCS, procedures are classified by their root operation rather than using the term "incision." The document emphasizes that accurate differentiation between these terms is important for correct medical coding and reimbursement.

1. INCISION VS EXCISION VS RESECTION
Cynthia Brown, MBA, RHIT, CCS
CyntCoding Health Information Services
Coding Yesterday’s Nomenclature Today®

2. STANDARDIZED TERMINOLOGY
One of the supposed drawbacks of the ICD-9 CM/PCS nomenclature is its lack of
standardized terminology. Standardized terminology is a universal language
designed to be shared and recognized by users. In the health care setting,
standardized terminologies are crucial for the accurate documentation of patient
care and outcomes. Likewise, for accurate coding and reimbursement the coding
nomenclature must also be standardized. Coding is essential for the capturing of
standards of care, influencing policy, and funding services; therefore standardized
terminology in coding is a must. Some of the benefits of standardized coding
terminology are:
– Increased reimbursement for services
– Decreased Third Party claim rejections
– Decreased compliance issues
– Decreased inefficient coding practices
– Increased ability to track services and diseases for research
– Increased ability to share data
– Increased consistency in educational guidelines for coding

3. Will Result in Accurate ICD-10 PCS Coding
RESECTION
INCISION
EXCISION
Knowing the Difference

4. DEFINITIONS & EXAMPLES FOR ICD-9 PCS
Resection is the surgical removal of part of an organ or structure. (Merriam-Webster)
Posterior Resection of Rectum (48.64)
Excision of Lesion or Tissue of
Diaphragm (34.81)
Excision is the surgical removal or resection of a body part. (Merriam-Webster)
Excision or Destruction of Breast Tissue
(85.20)
Excision of Lesion of Thyroid (06.31)
Incision is a cut made into the body during surgery. (Merriam-Webster)
Incision of Cerebral Meninges (01.31)
Reopening of Wound of Thyroid Field
(06.02)

5. DEFINITIONS & EXAMPLES FOR ICD-10 PCS
Resection is cutting out or off, without replacement, all of a body part. (ICD-10 PCS Standard Definition)
Open Resection Lung, RT (0BTK0ZZ)
Percutaneous Endoscopic Resection
Diaphragm, RT (0BTR4ZZ)
Excision is cutting out or off, without replacement of a portion of a body part.
(ICD-10 PCS Standard Definition)
Open Excision of RT Breast (0HBT0ZZ)
Percutaneous Excision of Pituitary Gland
(0GB03ZZ)
Incision is a cut made into the body during surgery. (Merriam-Webster)
Drainage of Cerebral Meninges, Open
(009100Z)
Percutaneous Removal Drainage Device,
RT Breast (0HPT30Z)

6. COMPARISON/CONTRAST
PROCEDURE ICD-9 PCS ICD-10 PCS
INCISION Incisions are performed for
several reasons (i.e., drainage of a
site, exploration,
insertion/removal of device,
removal of solid matter, and
reopening of operative site). The
coder can usually find these
procedures by going to the
alphabetical index under incision
and then the site of the incision.
The same procedures can be
found in the Medical and Surgical
Section; then by locating the Body
System and referring to the
particular Root Operation (i.e.,
Drainage, Inspection,
Insertion/Removal of device,
Extirpation). Incisional
procedures must be found using
their root operation rather than
the term “incision.” For example,
“drainage” for the “incision and
drainage” of a site.
EXCISION Excision can mean both the
partial and complete surgical
removal of a body part. The
removal of a lesion from a body
part is considered a partial
excision of a body part. On the
other hand, the excision of the
pituitary gland is the complete or
total removal of the pituitary
gland.
Excision means that only a
portion of the body part is
removed. The entire body part is
NEVER removed when the root
operation “excision” is used.
RESECTION Resection can mean both the
partial and complete surgical
removal of a body part. The
alphabetical index tells the coder
to “see also Excision, by site.”
Resection means that the entire
body part is removed. The partial
or excisional removal of a body
part is NEVER appropriate when
a resection is performed.

7. Coding Yesterday’s Nomenclature Today®
Cynthia Brown, MBA, RHIT, CCS
AHIMA Approved ICD-10 CM/PCS Trainer
CyntCoding Health Information Services
Phone: 404-992-8984/E-Fax: 678-805-4919
P.O. Box 3019
Decatur, GA 30031
cyntcoder@cyntcodinghealthinformationservices.com
www.cyntcodinghealthinformationservices.com
Coding Yesterday’s Nomenclature Today®

8. INCISION VS EXCISION VS RESECTION
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